Scaling-up Male Circumcision (MC) for HIV Prevention in Western Kenya: Risk Compensation and Infant MC
thesisposted on 21.07.2015 by Marisa R. Young
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ABSTRACT Background Male circumcision (MC) is approximately 60% effective against heterosexual HIV transmission among men. MC is being scaled-up across East and southern Africa. If men engage in riskier sex after becoming circumcised (termed “risk compensation”), the protective effect of MC could be diminished. Several governments in East and southern Africa have signaled their intention to scale-up Infant Male Circumcision (IMC) to mitigate potential risk compensation and because the procedure is simpler, safer and less expensive. Methods Data for this dissertation come from two sources. The first is the randomized controlled trial of male circumcision for HIV prevention and post-trial follow-up data collected between 2002 and 2010. The trial randomized 2,784 HIV negative men to immediate or delayed circumcision. After a median of 24 months of follow-up, uncircumcised men were offered the surgery and follow-up continued to 72-months. Generalized estimating equations models with incorporation inverse probability of treatment and censor weights were used to estimate the association between circumcision status and four time-varying measures of sexual risk-taking behavior: no condom use at last sex, sex the same day as meeting someone in the previous six months, >2 sexual partners in the previous six months and exchange of sex for gifts or money in the previous six months. The second data source is the Mtoto Msafi study and post-study routine infant circumcision service provision. The case-control study was conducted in 2010 at five government health facilities in western Kenya. Cases were mothers and fathers accepting circumcision for their son. Controls were parents who declined IMC services. A questionnaire comprising 41 questions was administered. Clinical variables relating to the circumcision procedure, including clinical provider, experience level of provider, age of the infant, and adverse event data were collected during the study and after study completion. Results In the risk compensation analysis, no condom use at last sex increased modestly over time for both circumcised and uncircumcised men (OR for 6-month increase in time 1.06). Compared to uncircumcised men, circumcised men had increased odds of no condom use at last sex (OR=1.17, p=0.006). There was no evidence of risk compensation in the other sexual behavioral outcome variables. In the infant circumcision analysis, factors associated with accepting IMC among mothers in multivariable logistic regression modeling were: father circumcised, both partners Luo (vs. father uncircumcised, both partners Luo OR=5.47, p<0.001) and agreeing with the father about the IMC decision (OR=5.00, p<0.001). Among fathers, factors associated with accepting IMC were: being circumcised and Luo (vs. uncircumcised and Luo OR=3.96, p=<0.001) and having higher endorsement of MC (OR=3.79, p<0.001). Fathers were the primary decision makers in most instances (66%). Few parents (3%) reported they would prefer a future son to remain uncircumcised. With respect to safety, the overall AE rate among infants reviewed post-operatively was 2.7% (18/678; 95%CI: 1.4, 3.9). There was one severe AE involving excision of a small piece of the lateral aspect of the glans penis. Other AEs were mild or moderate and were treated conservatively. Babies one month of age or older were more likely to have an AE (OR 3.20; 95%CI: 1.23, 8.36). AE rate did not differ by nurse versus clinical officer or number of previous procedures performed. Conclusions Both circumcised and uncircumcised men were less likely to use condoms over time. Further studies on risk compensation following MC may not be warranted. Fathers are important in the IMC decision-making process. Fathers, as well as mothers, should be targeted for optimal scale-up of IMC services. Circumcision programs should offer services for males of all ages, since male circumcision at some age is highly acceptable to both men and women. IMC services provided in Kenyan Government hospitals in the context of routine IMC programming have AE rates comparable to those in developed countries. The optimal time for IMC is within the first month of life.